Daniel D. Eun

Novel Use of Indocyanine Green for Intraoperative, Real-time Localization of Ureteral Stenosis During Robot-assisted Ureteroureterostomy

OBJECTIVEnTo present a novel method to intraoperatively localize ureteral strictures during robot-assisted ureteroureterostomy via indocyanine green (ICG) visualization under near-infrared (NIR) light.nnnMATERIALS AND METHODSnSeven patients underwent robot-assisted ureteroureterostomy for ureteral stricture by a single surgeon (D.D.E.). Intraoperative localization of ureteral stricture involved instilling ICG (25 mg in 10 mL distilled water) above and below the level of stenosis through a ureteral catheter or a percutaneous nephrostomy tube, or both. The fluorescent tracer was detected as a green color using the NIR modality on the da Vinci Si (Intuitive Surgical, Sunnyvale, CA). All patients consented to off-label use of ICG after full disclosure.nnnRESULTSnIntraoperative ICG injection and visualization under NIR light assisted in the performance of a tension-free anastomosis in all patients. At the time of surgery, mean age was 55.7 ± 12.4 years and mean body mass index was 30.3 ± 5.8 kg/m(2). Mean operative time was 171.3 ± 52.4 minutes, mean estimated blood loss was 175.0 ± 146.5 mL, and mean length of ureteral excision on pathologic analysis was 1.6 ± 0.7 cm. There were no immediate or delayed adverse effects attributable to intraureteral ICG administration. Mean hospital length of stay was 1.6 ± 1.5 days, with no postoperative complications. Mean follow-up was 5.9 ± 1.5 months, and all cases were clinically and radiographically successful at last follow-up.nnnCONCLUSIONnIntraureteral injection of ICG with visualization under NIR light allows for real-time delineation of the ureter. Additionally, ICG administration aids in discerning healthy ureter from diseased tissue, further assisting successful robotic ureteral repair.

Augmented-reality-based skills training for robot-assisted urethrovesical anastomosis: a multi-institutional randomised controlled trial.

To validate robot‐assisted surgery skills acquisition using an augmented reality (AR)‐based module for urethrovesical anastomosis (UVA).

Robotic management of genitourinary injuries from obstetric and gynaecological operations: a multi-institutional report of outcomes.

To evaluate the utility of robotic repair of injuries to the ureter or bladder from obstetrical and gynaecological (OBGYN) surgery

Single Surgeon Experience with Robot-Assisted Ureteroureterostomy for Pathologies at the Proximal, Middle, and Distal Ureter in Adults

PURPOSEnTo describe our initial experience with robot-assisted ureteroureterostomy (RUU) at the proximal, middle, and distal ureter.nnnMATERIALS AND METHODSnTwelve consecutive patients underwent RUU by a single surgeon (D.D.E.) between July 2009 and November 2012. Indications included three iatrogenic injuries, two impacted stones, two ureterovaginal fistulas, two idiopathic ureteral strictures refractory to conservative treatment, one primary transitional cell carcinoma of the ureter, one colon cancer metastasis to the ureter, and one invasive endometriosis. There were two proximal, three middle, and seven distal ureteral pathologies.nnnRESULTSnTension-free anastomosis was achieved in all 12 patients. All patients with proximal and middle ureteral pathology received concomitant downward nephropexy (DN) as a standard part of RUU. Mean age of patients at the time of surgery was 52 years (range 30-69), mean body mass index was 30.0u2009kg/m(2) (range 21-38), mean operative room time was 190 minutes (range 104-354), mean estimated blood loss was 181u2009mL (range 50-400), and mean length of excised ureter on pathologic analysis was 2.0u2009cm (range 1.0-4.5). There was one intraoperative complication in which liver and gallbladder laceration occurred during trocar placement. Mean length of hospital stay was 1.4 days (range 1-5), and there were no postoperative complications. Mean follow up was 10 months (range 3-36). One patient had a ureteral stricture recurrence at 7 months postoperatively that led to renal unit loss and eventual nephrectomy.nnnCONCLUSIONnRUU is feasible, safe, and demonstrates good outcomes for pathologies at the proximal, middle, and distal ureter. Concomitant DN during RUU may assist in achieving a tension-free anastomosis for proximal and middle ureteral repairs.

Robot-assisted partial nephrectomy: continued refinement of outcomes beyond the initial learning curve.

To evaluate trends in peri‐operative outcomes of 250 consecutive cases beyond the initial learning curve (LC) of robot‐assisted partial nephrectomy (RAPN) among multiple surgeons.

Selective arterial clamping does not improve outcomes in robot-assisted partial nephrectomy: a propensity-score analysis of patients without impaired renal function.

To assess the benefit of selective arterial clamping (SAC) as an alternative to main renal artery clamping (MAC) during robot‐assisted partial nephrectomy (RAPN) in patients without underlying chronic kidney disease (CKD).

Stone Formation from Nonabsorbable Clip Migration into the Collecting System after Robot-Assisted Partial Nephrectomy

We describe a case in which a Weck Hem-o-lok clip (Teleflex, Research Triangle Park, USA) migrated into the collecting system and acted as a nidus for stone formation in a patient after robot-assisted partial nephrectomy. The patient presented 2 years postoperatively with left-sided renal colic. Abdominal computed tomography scan showed a 10 millimeter renal calculus in the left middle pole. After using laser lithotripsy to fragment the overlying renal stone, a Weck Hem-o-lok clip was found to be embedded in the collecting system. A laser fiber through a flexible ureteroscope was used to successfully dislodge the clip from the renal parenchyma, and a stone basket was used to extract the clip.

Robotic Ureteral Reconstruction Using Buccal Mucosa Grafts: A Multi-institutional Experience

BACKGROUNDnMinimally invasive treatment of long, multifocal ureteral strictures or failed pyeloplasty is challenging. Robot-assisted buccal mucosa graft ureteroplasty (RBU) is a technique for ureteral reconstruction that avoids the morbidity of bowel interposition or autotransplantation.nnnOBJECTIVEnTo evaluate outcomes for RBU in a multi-institutional cohort of patients treated for revision ureteropelvic junction obstruction and long or multifocal ureteral stricture at three tertiary referral centers.nnnDESIGN, SETTING, AND PARTICIPANTSnThis retrospective study involved data for 19 patients treated with RBU at three high-volume centers between October 2013 and July 2016.nnnSURGICAL PROCEDUREnRBU was performed using either an onlay graft after incising the stricture or an augmented anastomotic repair in which the ureter was transected and re-anastomosed primarily on one side, and a graft was placed on the other side.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnPreoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed.nnnRESULTS AND LIMITATIONSnThe onlay technique was used for 79%, while repair was carried out using the augmented anastomotic technique for the remaining cases. The reconstruction was reinforced with omentum in 95% of cases. The ureteral stricture location was proximal in 74% and mid in 26% of cases. A prior failed ureteral reconstruction was present in 53% of patients. The median stricture length was 4.0cm (range 2.0-8.0), operative time was 200min (range 136-397), estimated blood loss was 95ml (range 25-420), and length of stay was 2 d (range 1-15). There were no intraoperative complications. At median follow-up of 26 mo, the overall success rate was 90%.nnnCONCLUSIONSnRBU is a feasible and effective technique for managing complex proximal and mid ureteral strictures.nnnPATIENT SUMMARYnWe studied robotic surgery for long ureteral strictures using grafts at three referral centers. Our results demonstrate that robotic buccal mucosa graft ureteroplasty is a feasible and effective technique for ureteral reconstruction.

Predicting Complications Following Robot-Assisted Partial Nephrectomy with the ACS NSQIP® Universal Surgical Risk Calculator

Purpose: We evaluated the predictive value of the ACS NSQIP® (American College of Surgeons National Surgical Quality Improvement Program®) surgical risk calculator in a tertiary referral cohort of patients who underwent robot‐assisted partial nephrectomy. Materials and Methods: We queried our prospectively maintained, multi‐institutional database of patients treated with robot‐assisted partial nephrectomy and input the preoperative details of 300 randomly selected patients into the calculator. Accuracy of the calculator was assessed by the ROC AUC and the Brier score. Results: The observed rate of any complication in our cohort was 14% while the mean predicted rate of any complication using the calculator was 5.42%. The observed rate of serious complications (Clavien score 3 or greater) was 3.67% compared to the predicted rate of 4.89%. Low AUC and high Brier score were calculated for any complication (0.51 and 0.1272) and serious complications (0.55 and 0.0352, respectively). The calculated AUC was low for all outcomes, including venous thromboembolism (0.67), surgical site infection (0.51) and pneumonia (0.44). Conclusions: The ACS NSQIP risk calculator poorly predicted and discriminated which patients would experience complications after robot‐assisted partial nephrectomy. These findings suggest the need for a more tailored outcome prediction model to better assist urologists risk stratify patients undergoing robot‐assisted partial nephrectomy and counsel them on individual surgical risks.

Robotic Ureteroplasty with Buccal Mucosa Graft for the Management of Complex Ureteral Strictures

Purpose: Surgical management of proximal and mid ureteral strictures that are not amenable to primary excision and anastomosis is challenging. Although a buccal mucosa graft is commonly used during substitution urethroplasty, its use in substitution ureteroplasty is limited. We describe our technique of robotic ureteroplasty with a buccal mucosa graft to manage complex ureteral strictures and we report our outcomes. Materials and Methods: We retrospectively reviewed the records of 12 patients who underwent robotic ureteroplasty with a buccal mucosa graft between September 2014 and June 2016. The indication for the procedure was a proximal or mid ureteral stricture not amenable to primary excision and anastomosis. The primary outcomes were clinical success, absent symptoms on ureteral pathology and radiological success, defined as absent ureteral obstruction on retrograde pyelography, renal scan and/or computerized tomography. Results: Four of the 12 patients (33.3%) had a ureteropelvic junction stricture, 4 (33.3%) had a proximal stricture and 4 (33.3%) had a mid ureteral stricture. Eight of the 12 patients (66.7%) had previously undergone failed ureteral reconstruction. Median stricture length was 3 cm (range 2 to 5). Median operative time was 217 minutes (range 136 to 344) and mean estimated blood loss was 100 ml (range 50 to 200). Median length of stay was 1 day (range 1 to 6). At a median followup of 13 months (range 4 to 30) 10 of the 12 cases (83.3%) were clinically and radiologically successful. Conclusions: Robotic ureteroplasty with a buccal mucosa graft is associated with low inherent morbidity. It is an effective way to manage complex proximal and mid ureteral strictures.